Healthcare Provider Details

I. General information

NPI: 1386160513
Provider Name (Legal Business Name): ORTHONORTHRUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 W TOWN PL STE 106
ST AUGUSTINE FL
32092-2820
US

IV. Provider business mailing address

PO BOX 4389
ST AUGUSTINE FL
32085-4389
US

V. Phone/Fax

Practice location:
  • Phone: 904-466-1179
  • Fax: 904-823-8967
Mailing address:
  • Phone: 904-466-1197
  • Fax: 904-823-8967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberOS7217
License Number StateFL

VIII. Authorized Official

Name: TOD NORTHRUP
Title or Position: MEDICAL DIRECTOR, OWNER
Credential:
Phone: 904-466-1197